16 April 2009

If the NHS spends £7 billion on general practice how much do you think is spent on NHS administration? Would it be ten per cent of this figure? Twenty per cent perhaps? Half? No, that surely would be too much. On the other hand spending on NHS management has been going up recently. In fact it has doubled in the past 5 years of reform. So perhaps spending on NHS management may be a little more than you think. Just how much more you can find out here.

Posted by
Dr Grumble

4 comments:

I am going to reveal my prejudice that simply measuring the weight of cost in spending on NHS management / administration in this manner reveals virtually nothing of real value to the goal of delivering good care.

It's a bit like that other classic rubbish argument that the NHS 'now has more managers than beds'. The NHS probably has more windows than beds. It probably has more tables than beds. Counting furniture smacks of an autistic tendency to fail to diagnose much that is truly useful.

There is, of course, a reasonable argument that every element of public spending, such as NHS admin / management costs, should be open for debate or discussion. It is an argument in which I totally believe.

However, there is a significant danger that this can contribute to a world view that NHS management (which, in its simplest terms, is the assessment of value added; quality of life gained; and public spending well-used) is not something in which we should invest, and is not something that we need.

I will also reveal my prejudice that this world view of NHS management is total horseshit.

Is all of NHS management good?

No.

Is NHS management politicised to a significant degree?

You betcha. (This is, of course, a corollary of the 'free at the point of use' bit).

Is the culture of NHS management open to debate and discussion - particularly with clinicians?

Don't make me laugh.

Should we therefore give up on it?

That is a difficult question. It is tempting to answer in the negative. But I don't. Instead, let's try a few of these for size:

Do we sincerely believe that the BMA, the Royal Colleges and the GMC have been doing a much better job of assessing value added and public resource well used? (Because someone has got to do it)

Do we believe that outcome measures should be shared in such a way that risk should be genuinely shared with the public, rather than by paternalistic proxy?

Do we have any realistic way of determining what would be an appropriate level of expenditure?

Or in discussing management costs in such a way, are we making the mistake of focusing on processes, as opposed to outcomes?

I'm sorry if these views seem antagonistic: I don';t mean them to be so. But a debate is probably doomed to be sterile polemic if it's only framed in these 'how much? shock horror!' terms.

The newspapers like shock horror about spending on NHS managers and the public like to tut-tut. Comparing the amount spent on general practice with amount spent on management of the whole of the NHS is a bit silly but it might make people think. The doubling of spending on management is more meaningful. Actually Dr G is one of the few people that thinks that, at some levels, the NHS has been undermanaged. He was also one of the ones to have pointed out that if you run a market system you have to employ a lot of people to run the market and that it is very doubtful whether they can possibly save more than they themselves cost. There are also, as you point out Andy, a lot of managers whose job it is to further some political aim.

Could more clinical involvement in management help? Theoretically it could. In practice clinicians moving in the management direction see where their bread is buttered, put on a management hat and lay down the stethescope.

Not a lot of clinicians there - and in Steve Field of the RCGP, a single practicing GP. Barbara Hakin has 'gone over to the dark side' of management some years ago.

It is really sad that clinicians can't easily get involved in management without having to go native. It's also sad that clinicians and managers appear to be trained to distrust of not dislike each other. What I notice in common about successful and enduring managers in the NHS is that they always knew they had to take their clinicians with them as far as possible, and manage the inevitable fallings-out with real diplomatic skills.

It's sad if there are not many clinicians. We very much need clinicians in management who do not 'go native' but persist in keeping the clinical perspective at the forefront of the management process. My own feeling is that in some places this aspect of management is getting worse and not better as the managers' eyes are taken off the ball by all-consuming targets and pressing management goals such as achieving foundation status.

You are, of course, right about successful managers taking the clinicians with them. David Nicholson himself is one of these. I have heard him speak from the heart on the topic. Managers and clinicians very much need each other but somehow things just don't gel as they should. There are all sorts of reasons for this. The two groups are undoubtedly very suspicious of one another. Both parties are to some extent at fault. Edicts from the top have not been altogether cognisant of the views of clinicians and many GPs believe that the government has deliberately set out to poison them in the eyes of the public. That's not a good starting point if you are looking to improve things.